Thyroid Imaging Reporting and Data System (TIRADS)

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Thyroid Imaging Reporting and Data System (TIRADS) for solid nodules: the impact of quantitative strain elastography for better stratification of cancer risks
25 Iun, 2014Thyroid Imaging Reporting and Data System (TIRADS) for solid nodules: the impact of quantitative strain elastography for better stratification of cancer risksStudy group: All cases with uninodular or polinodular goiter, larger than 5 mm in diameter, that have planned surgery in the near future or will have indication for surgery, after the evaluation will be considered in this analysis.
FNAB will be recommended in all solid nodules.
Only cases with performed UGFNA will be considered in the final evaluation.In the cases of polinodular goiter we will considered the dominant nodule or the nodule with malignancy.The score for the images will be made according to the TIRADS classification proposed by Russ:
TIRADS 2 (constantly benign aspect): simple cyst, spongiform nodules, “White knight”, isolated macrocalficication, nodular hyperplasia: nonencapsulated, mixed nodule, with solid portion, izoechoic, expansible, vascularized nodules with hyperechoic spots
TIRADS 3 (very probably benign): no signs of high suspicion, isoechoic or hyperechoic, partial in capsulated
TIRADS 4A (undetermined): no signs of high suspicion, mildly hypoechoic, incapsulated nodule
TIRADS 4B (suspicious): irregular shape/ taller than wide, irregular borders, Microcalfications, markedly hypoechoic, high stiffness with elastography; 1 or 2 signs and no lymph node metastasis
TIRADS 4C -5 (highly suspicious): irregular shape/ taller than wide, irregular borders, Microcalfications, markedly hypoechoic, high stiffness with elastography than; 3 to 5 signs and/or lymph node metastasis
Proposed method
Ultrasound evaluation
Conventional and strain elastography will be performed with a Hitachi Preirus, multi frequency linear probe, 6-13 MHz, Hitachi Medical Corporation, Tokyo, Japan. Strain elastography will be performed, as recommended with mild external pressure, always checked on the pressure scale, using only 3-4 grade images and loops. Two observes with more than 5 years of experience in thyroid ultrasound, independently will evaluate the nodules using TIRADS classification and strain elastography. All the above-mentioned conventional ultrasound characteristics will be checked for each evaluated nodule. For each nodule, the observers will record not only the qualitative ES score, according to the standard blue red green color map, but also will calculat the strain ration comparing the nodule with the surrounding healthy, non nodular thyroid tissue. The Tsukuba classification will used for qualitative SE.

Pathological report Each extracted piece will be conserved in formalin and embedded in paraffin, both nodular and apparent healthy surrounding tissue. The histological diagnosis, will be made in the Pathology Department of our hospital by the thyroid specialist. Imunohistochemical evaluation, HBME, CH-19, K067 and TTF reactions will be performed in selected cases.
Aim: The aim of the present study is to evaluate TIRADS with quantitative strain elastography for the assessment of thyroid nodules.

Surgical intervention Unilateral lobectomy or total thyroidectomy will be performed according to the bilateral or Uniateral lesion, and also the results of FNAB. In selected cases lymph node excision will be performed.,

DXA and vitamin D in postmenopausal women

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DXA and vitamin D in postmenopausal women
PATIENTS: All postmenopausal women that will performed DXA evaluation in Dr. D Medical Center, starting December 2013
Proposed Inclusion criteria: postmenopausal naïve patients, with no previous anti osteoporotic treatment or vitamin D supplementation.
Proposed Exclusion criteria: chronic use of medication with known bone impairment effect, metabolic bone disease, endocrine diseases, known malignancies, previous chemotherapy or radiotherapy, renal failure, renal phosphate leak, Paget’s disease
All patients will be questioned for the FRAX risk factors for osteoporosis, validated for Romanian population, FRAX will be calculated for each person.
DXA and blood samples will be performed in the same day. The clinical decision was made afterwards for each case separately.
Blood samples will be taken in the day of DXA measurement. The blood was centrifuged the same day, and the serum concentrations for 25 OH vitamin D were measured in all cases, by the same laboratory unit, the M&C Medical Laboratory. CLIA method will be used, for the assessment of total 25 OH vitamin D, with an interassay coefficient of variation 0f 5.5-9.2%. The minimum detection limit is 4 ng/mL.
We define insufficiency of vitamin D in case of serum values lower than 30 ng/mL respectively deficiency for values lower than 10 ng/ml. Levels higher than 30 ng/ml were considered sufficient .
DXA measurements will be performed on the same device, Dexxum T osteodensitometer, Osteosys Company (South Korea), a pencil beam antero-posterior device. The calibration of the DXA system will be made daily with the European Forearm Phantom. All measurements will be performed and interpreted by the same technician, Dr. D.R., ISCD licensed since 2008.
Aim of the study: The aim of our work is to asses the impact of vitamin D level on bone mineralization, in postmenopausal women, with and without osteoporosis..

Clinical study: Monthly hormonal levels testing in pregnant women

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Clinical study: Monthly hormonal levels testing in pregnant women with know asymptomatic autoimmune thyroid disease

Patient group: Female with known autoimmune asymptomatic thyroid disease.

All females, known with this pathology, will be actively followed during pregnancy, whenever this pregnancy will be diagnosed.

Control population: Aged matched women, without autoimmune thyroid disease, that will be questioned about evolution of pregnancy, and the same offspring data.

Follow-up: After the diagnostic of pregnancy, monthly follow-up with clinical evaluation, hormonal assays (FT3, FT4, in the same medical lab), thyroid ultrasound in the 1st and 3rd trimester. Postpartum evaluation in week 8 will be organized in all cases.

Offspring data will be recorded: week of birth, birth weight and length, given APGAR score.

After the confirmation of pregnancy, SCH was defined as a serum TSH level > 2.5 mIU/L (1st trimester) or > 3 mIU/L (2nd and 3rd trimesters), but < 10 mIU/L with normal serum free T4 (FT4). Overt hypothyroidism (OH) was defined as TSH level > 2.5 mIU/L (1st trimester) or 3 mIU/L (2nd and 3rd trimesters) with decreased FT4 concentration or TSH > 10 mIU/L, regardless of the FT4 levels. The definition were used according to the ATA recommendations

Intervention: In al cases that are diagnosed with autoimmune thyroid disease, if the TSH values will increase more than the recommended threshold (2.5 mIU/L) supplemental therapy with Tetraiodothyroinine, EUTHYROX, will be offered to the patients. Monthly increment of supplemental therapy will be recorded.

Aim: The aim of  this study is  to evaluate the occurrence of SCH in cases with known autoimmune thyroid disease which were in an euthyroid state prior to pregnancy, and to assess the association between supplemental treatments administered, which have a positive impact on the outcome of the pregnancy

Clinical study: Nodular thyroid cancer. Diagnostic value of real time elastography

Clinical study: Nodular thyroid cancer. Diagnostic value of real time elastography

Patient group: The study is a prospective study enrolling cases seen in the Endocrinology Office, Center Dr.D, affiliated with the University of Medicine and Pharmacy “Victor Babes” Timisoara, starting January 2011. There were included cases with one or more thyroid predominant solid nodules, with volumes higher than 0.20 mL, in patients that did not accept FNAB.

We considered cases that were referred to surgery. All surgical procedure will be performed in the Surgical Department of the same University. All patients are asked to signed the Inform Consent.

Evaluation: We will perform the final evaluation of each patient on a Hitachi EUB 7500 HV machine with 6-13 MHz variable frequency linear probe, with Doppler and elastography software, with recording of frames of all lesions prospectively on color elastography color map 1 (red-yellow-green-blue color map); Hitachi Medical System, Tokyo, Japan.

Conventional, Power Doppler US and Elastography

In preoperative period all patients will be examined  by the same operator (D.S.), using High Resolution B-mode grey scale ultrasonography (US), Power Doppler ultrasonography (PD) and Real Time ultrasound elastography (USE) using the same machine.  We analyses at each nodule the following parameters: echogenity (hyper-, iso and hyperecoic compared to the normal thyroid parenchyma); presence or absence of halo phenomena; irregular or well defined margins, shape (dominant dimension); intranodular homogeneity; presence of calcification:  spot microcalcifications: hyperechoic spots less than 2 mm, without acoustic shadowing, macrocalcifications round solitary/eggshell or nonspecific calcification. Color flow Doppler pattern was defined as: absence of any blood flow, perinodular with no or scare intranodular blood flow, marked intranodular blood flow or unique dominant intranodular vessel.

The US elastography will be performed during the same US examination, by the same observer. The US elastogram will be displayed, as usual, over de 2B map, with the scale ranging from red – soft tissue to blue – hard lesions with no strain. The compression applied to the neck will be always between double-checked by the standardized real-time measurement displayed on the screen. Only moderate pressure with the scale 3 to 4 were applied and used for the analysis. The images will be classified by the UENO 5 point scale (18): ES 1 = soft, elasticity (green color) within whole lesion, ES 2 = soft, elasticity (green color) in more than 50% of the lesion, especially in the center, ES 3 = intermediate, blue in circa 50% of the area predominant in the center of the lesion (elasticity only at the periphery of the nodule), ES 4 = hard, no elasticity, predominant blue color, ES 5 = no elasticity in the nodule and surrounding area.

Treatment

All patients with predominant solid nodules will be referred to surgery. The surgical protocol will be: total lobectomy on the site of the nodule. Total thyroidectomy will be recommended as a principle in cases with elastography score of 4. All excised pieces will be send to the Pathology Department.

Histopathological diagnosis

Each piece extracted in the surgery will be formalin-fixed and paraffin embedded both for nodular and apparent healthy thyroid tissue. The histological diagnosis will be made by the pathologist on duty on the day of surgery, according to the World Health Organization Guidelines. In selected cases imunohistochemical reactions were performed: HBME, CH-19, K067 and TTF

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The usefulness of real time elastography as a diagnostic tool for solid breast tumors: a prospective studyThe usefulness of real time elastography as a diagnostic tool for solid breast tumors: a prospective study

the-journey-of-elastography-background-current-status-and-future-possibilities-in-breast-cancer-diagnosis-4-638The usefulness of real time elastography as a diagnostic tool for solid breast tumors: a prospective study

Study patients: Starting January 2011, all ductal breast ultrasound evaluation were considered.

Inclusion criteria: solid nodules, with potential signs of malignancy during the ultrasonographic examination that had surgical indications. Additional magnetic resonance imaging (MRI) or mammography studies will be performed in selected cases. Gold standard comparisons for the diagnostic tests’ quality analyses will be considered the pathology report, after surgical removal of the nodule. Suspect lesion without pathology report will be not included in the final evaluation.

The study protocol is approved by the Timisoara Emergency Hospital’s ethics committee, and all participants in the study voluntarily signed a written informed consent form prior any study procedure or data collection.

Methods: We are equipped with a Hitachi EUB 7500 HV machine, with special breast probe, EUP- L53L, 92 mm, with water bag device, and small EUP-L74M 50 mm. We used ductal breast approach, with conventional grey scale 2B ultrasound, Color Doppler and strain elastography.   The same two operators will perform all ultrasonography examinations using the same device and probes. In all patients, high-resolution B-mode grey scale ultrasonography (US), color Doppler ultrasonography (CD), and RTE were performed. We prefer the ductal elastography because it offers a better perspective of the position of the nodules, a better differentiation between multicentric and multifocal lesions. The Breast Imaging-Reporting and Data System (BI-RADS) – US criteria were used in the evaluation of each nodule in conventional US mode.

RTE was performed during the same examination by the same operators and was displayed, in parallel with the 2B map. We used color map 1, with red color for soft tissues changing to blue color, for hard lesions. The examination was performed with low external pressure.  We applied the recommended medium external pressure in order to see the real elastic properties of the compressed tissues. We used the classic UENO scale for the evaluation of the qualitative images. An ES score of 4 or 5 will be considered to be significant for malignancy. The FLR will be determined in each case. Only scans with proper regions of interest will be considered. At least two measurements will be performed for each solid nodule in radial and antiradial sections. The ultrasound evaluation  will be performed prior to any invasive approach.

Surgical protocol and pathology examination The surgical intervention will consist of a either limited excision in cases of unique nodule, or total mastectomy in multicentric lessions. Axillary control with sentinel nodule examinations will be performed in all cases. Each biopsy piece will be sent to the pathology department for further analysis after it was formalin-fixed and paraffin embedded. The pathologist on duty will prepare the specimen for evaluation. Diagnostic will be made according to the National Cancer Institute classification. Receptor status evaluation will be performed in all cases with a possible malignant diagnosis.

Addressability issues: when is autoimmune thyroiditis a point in the evaluation
of spontaneous recurrent abortion in fertile women?

Thyroiditis

In all cases we performed the ultrasound evaluation of each patient on a Hitachi 7500 V device with a multiple frequency, 6-13 MHz variable, linear probe, with ultrasound and elastography software; Hitachi Medical System, Tokyo, Japan.

Evaluation

Clinical evaluation will be considered in: hypothyroidism symptoms and signs, thyroid palpation with goiter dignostic: Ia = goiter present only at clinical examination, Ib =visible goiter with neck in hyperextension, II = visible goiter in normal position, III = important visible goiter;

We will measured TSH, free thyroid hormones (FT4,FT3) regardless the menstrual period, prolactin (PRL), progesterone in the mid luteal phase (PRL in normal range = 127-637 mUI/L and progesterone in normal range = 5.3-86 nmol/L), and iodine homeostasis (iodine in serum, normal range= 46-70 μg/L).

The immunological evaluation constitutes in anti Tiroperoxidase antibodies (antiTPO Ab, normal range 1.5 UI/mL), anti-ovarian antibodies including gynecological exam and transvaginal ultrasound.

Aim: The present study aim to evaluate the impact of autoimmune thyroid disease on recurrent pregnancy loss.

Addressability issues: when is autoimmune thyroiditis a point in the evaluation
of spontaneous recurrent abortion in fertile women?

Stud group: Women with a positive history of spontaneous abortion, that will be referred to our Endocrine Unit, Dr. D Medical Center, affiliated with the Department of Obstetrics and Gynecology, University of Medicine and Pharmacy “Victor Babes” Timisoara, starting January 2010

We will include in our evaluation only sexually active women patients of childbearing age. Complete gynecological evaluation will be conducted in the University Clinic of Obstetrics and Gynecology, County Hospital, Timisoara.

The inclusion criteria are: at least one prevalent spontaneous abortion, no known gynecological disease, no infections associated with recurrent abortion, self-referral/ gynecological-referral and normal values in screening for thromboembolic diseases.

The exclusion criteria are: organic (tumoral) hyperprolactinemia, adrenal diseases, progesterone insufficiency due to follicular phase deficit, hypercortisolemia, known disease/mutation associated increased clotting process, genetic mutation in one partner and gynecological diseases.

Proposed definition:

We consider the clinical hypothyroidism when TSH was >4 mUI/L, associated with decreased FT4 and/or FT3 values, subclinical hypothyroidism when TSH was > 4 mUI/L associated with normal FT4 and/or FT3 values(, progesterone deficiency when showed decreased progesterone values in the mid-luteal phase, organic hyperprolactinemia when MRI confirmed hypophisys tumor with repeated increased PRL levels, hypercortisolemia when the basal cortisol levels were increased, with no proper inhibition response (less decrease than 50%) and auto- immune thyroid disease (type 1, euthyroid with normal TSH values, type 2, persistent hypothyroidism and type 3, hyper/euthyroidism with suppressed TSH).

Impact of weight loss on sexual satisfaction in overweight adult women

Impact of weight loss on sexual satisfaction in overweight adult women

Study group: We will recruit all overweight women that will come in our Endocrine Unit for a weight loss program

Inclusion criteria: sexual active overweight women, in a stable relationship for at least 1 year.

Exclusion criteria: Thyroid pathology, PCOS, Cushing disease/syndrome, chronic liver and renal disease, any type of malignancy, use of neuroleptic drugs, diagnosed depression, single women

Intervention: all women will be evaluated wilt bioimpedance measurement, at base line, and monthly after follow-up. Weight loss program – minus 1000 calories daily

Completion of the FSFI questionnaire will be made at baseline and after 3,6 9 and 12 months of weight loss program.

Only women compliant to the full 12-month program will be considered in the final analysis.

Dropouts will be regrouped in the control group

AIM: to see if significant weight loss can change the parameters of sexual quality in overweight wome

QUS Threshold values in diagnostic of bone mineral impairment, in cases with end stage renal disease

QUS Threshold values in diagnostic of bone mineral impairment, in cases with end stage renal disease,

Study population: women and men, with ESRD, stage V under chronic hemodialysis for at least 1 year.

Evaluation: We will perform a DXA scan (Hologic Inc, antero-posterior technique, Delphi W device) on the lumbar spine and non-dominant femoral neck. Total BMD CV is 1.0%, ACF = 1.029, BCF = 0.993, TH = 8.076. The femoral neck and the total hip will be analyzed separately.

QUS will performed with the Sahara device (Hologic Inc.), using the dry technique, in the non- dominant leg, the device being one of the two validated QUS devices worldwide (ISCD 2007). SOS (speed of sound), BUA (broadband ultrasound attenuation) and also the QUI (combined value of SOS and BUA) will be measured for each patient.

Each device will be operated by only one technician.

AIM: We have try to analyze and determine the domains in which QUS can be properly used in the diagnosis of bone demineralization in patients with ESRD. Screening or final diagnosis are equally useful in the complex diagnostic algorithm, used in the Center for Hemodialysis and Renal Transplantation of the Clinical Emergency County Hospital in Timisoara

Osteoporosis

Fracture risk reduction in ESRD, under chronic hemodialysis cases, treated with antiresorptive medication

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Fracture risk reduction in ESRD, under chronic hemodialysis cases, treated with antiresorptive medication

Study population: ESRD cases, under chronic hemodialysis, with secondary hyperparathyroidism, with high turnover bone disease, with bone demineralization.

Inclusion criteria: patients that will have the mentioned criteria, and were willing to use the antiresorptive medication: Bisphosphonate for at least 12 months.

Follow-up: yearly follow up by means of DXA.

The same DXA device will be used: Hologic Inc, antero-posterior technique, Delphi W device) on the lumbar spine and non-dominant femoral neck. Total BMD CV is 1.0%, ACF = 1.029, BCF = 0.993, TH = 8.076. The femoral neck and the total hip will be analyzed separately.

Recording all musculoskeletal problems during the follow-up.

Proposed follow –up = at least 4 years.

Control group:  ESRD cases, under chronic hemodialysis, with secondary hyperparathyroidism, with high turnover bone disease, with bone demineralization cases that did not agree to take the bisphosphonate medication.

AIM of the study: to see in bisphosphonate treatment will decrease the fracture risk in ESRD cases with secondary hyperparathyroidism.

Diagnostic algoritm for identifying the type of bone turnover in patients with renal osteopatia on chronic hemodialysis

Diagnostic algoritm for identifying the type of bone turnover in patients with renal osteopatia on chronic hemodialysis

The study group will comprise cases recruited from the patients of the Clinic of Hemodialysis and renal transplantation, at the Clinical Emergency County Hospital, Timisoara, that agreed to complete the follow up.

The evaluation algorithm will comprise the following:

– Anamnesis, clinical exam, measurement of height, weight (after dialysis session);

– Seric biochemical assays: calcemia, phosphatemia, total alkaline phosphatase, iPTH (ELISA, normal values 8.0-68 pg/mL), 25-HO vitamin D (CHEIM Diasorin Liason, normal values over 30 ng/mL); we also determined the values for osteocalcin – OS (ELISA normal values: 3.1-13.7 ng/mL) and bone specific alkaline phosphatase – BAP (ELISA normal values lower than 90 U/L).

All cases will perform standard X-ray evaluation of skull – profile, antero-posterior pelvis, bilateral hands and feet, antero-posterior image, lateral view of lumbar and/or toracal spine. DXA will be performed on lumbar spine, non-dominant femoral neck.

Only patients that agreed to all the follow up will be considered in the final analysis. Drop out will not be considered in the retrospective analysis.

Diagnostic criteria: iPTH over 400 pg/mL is characteristic for increased bone turnover.6The association of high turnover (BAP values > 90 U/L), or the presence of low turnover OS values, below 3.1 ng/mL, suggests the type of bone turnover.14 Vitamin D deficiency implies bone mineralization defects. Visualization of the parathyroid glands on ultrasound examination will confirm secondary hyperparathyroidism.

The combined information will permit to use the recommended iPTH values for ESRD patients: more than 3 times the maximum normative value for diagnosing secondary hyperparathyroidism, respectively values less than 100 pg/mL for low turnover bone disease. 1000 pg/mL will be the threshold value for iPTH in diagnosing severe, tertiary hyperparathyroidism.

Aim: We want to develop an algorithm for diagnosing the type of bone disease in patients with ESRD on chronic hemodialysis. Combining clinical, biochemical, hormonal and newer bone remodeling markers and bone density measurements should increase the diagnostic quality in our this special category of patients.

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